Inspection on 07/12/05 for New Bassett House

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

New Bassett House 20/06/07

New Bassett House 11/04/06

New Bassett House 15/07/05

New Bassett House 03/02/05

New Bassett House 04/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE New Bassett House New Bassett House Park Avenue Shirebrook Nr Mansfield Derbyshire NG20 8JW Lead Inspector Bridgette Hill Unannounced Inspection 7th December 2005 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service New Bassett House Address New Bassett House Park Avenue Shirebrook Nr Mansfield Derbyshire NG20 8JW 01629 580000 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Derbyshire County Council Susan Ina Elsden Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th July 2005 Brief Description of the Service: New Bassett House is a home offering 40 places to older persons, which now includes 2 places as part of an intensive assessment or intermediate care project. As well as longer-term care the home offers short-term respite care, which had been used by a number of service users to acquaint themselves with the home before making a final decision about their future. The home is built on one level and is situated in a residential area, near to the town centre of Shirebrook. Arranged on 3 wings the home offers a range of communal rooms to suit different purposes and access for persons with a physical mobility problem is assisted by wide corridors and an open central area. Facilities have been arranged with a domestic style in mind and there is good access to the outside areas of the home. Access to outside professionals is routinely arranged and the home benefits from the active support of a local GP who had assisted to raise the profile of health care in the home New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced one which took place over 4 hours. During the inspection 1 staff member and 3 residents were spoken with. The Manager was spoken to by telephone. Various records including care planning records were examined the findings are recorded in the body of this report. This is the second inspection of the home year and this report should be read in conjunction with the report of the visit dated 15th July 2005. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Service users were usually given opportunities to visit and try the home before making decisions regarding being admitted on a permanent basis. EVIDENCE: Discussions with staff confirmed that there was not always a written assessment of service users completed by staff from the home prior to admission. There tended to be a reliance on information from Care Managers however they would not necessarily be able to judge how a service user would fit in at the home and whether all their needs could be met. Some service users did visit the home for a trial day but again written assessments by staff at the home were not always available. A format for assessments to be written on was available. Emergency admissions were accepted by the home on occasions. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 8 Some service users used the home on a short-term care basis prior to moving into the home permanently. Completed Terms and conditions of residency contract were in files that had been signed by service users or their representatives. This meets a previous requirement. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11 Care plans had improved since the last visit and there was consultation with service users regarding their plan of care. EVIDENCE: A sample of two service users care files were examined. It was evident that written care plans had significantly improved since the last inspection. There were signatures to evidence that service users had been consulted regarding their plan of care and review dates were evident. Care plans available provided details of how care was to be delivered and a range of risk assessment tools were available and implemented. Some key details were missing form care documents such as the addresses of the next of kin and admission dates. There was good documentation throughout care documents of visits made by GP’s, opticians and chiropodists. The storage and administration of medicines was examined. A list of specimen signatures was available. Not all handwritten entries on medication administration records had been doubly signed and verified. Where the dosage New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 10 of medications had changed a new instruction on the medication administration records had not been started instead amendments to the previous instruction were made. Where a variable dosage was prescribed staff were not recording the actual dosage being administered. Work had been implemented to ensure that any homely remedies administered were recorded on the service users medication administration record. The drug reference book available was dated September 2004. As has been identified at previous inspections night staff had not received accredited medications training. It was reported that the dangerous practice of medications being pre-dispensed by staff from original packaging into pots was being used with night staff then dispensing the medications. This is an outstanding requirement from previous inspections. Work was required to ensure that service users were consulted regarding their post death wishes as none of the care files examined contained information that this had been considered. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards in this section were formally assessed at this visit. Observations of the lunchtime meal were made. This was served attractively with tables being set with tablecloths, cruets and gravy served in gravy boats at the tables. Service users spoken to were generally complimentary of the food served. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards in this section were formally assessed at this visit. The previous requirement relating to staff receiving Protection of vulnerable adults training was assessed. Some but not all staff had received training and more staff were booked to go on courses. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26 The home presents as being comfortable, clean and well maintained and is considered to be suitable to meet the needs of service users EVIDENCE: A sample of service users bedrooms were viewed. These were found to be clean and well personalised. Lockable facilities were available in each room and some service users held the key to their room. It was not documented in the care files examined if service users were routinely assessed and offered the key to their rooms. A range of communal areas were available which were homely and well maintained. The laundry area was satisfactory and fit for purpose. It was found that that the laundry and sluice areas were not locked and chemical cleansers were being openly stored in them. These must be secured to prevent possible accidental ingestion. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 14 In toilet and bathroom areas communal supplies of a foam soap cleanser were being used. The cans these were in were found to be faecally stained and pose a cross infection risk. These must be used on a personal service user base only. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Generally the provision of training appeared to be adequate however there were crucial gaps in the training programme that had the potential to adversely affect practices being implemented in the home. EVIDENCE: Staff spoken to said they felt they were offered good training opportunities. Records of staff training were examined. These confirmed that staff had attended a range of training including fire safety, moving and handling, basic food hygiene first aid and management. Some training had been undertaken on Protection of vulnerable adults but not all staff had yet completed this. It is outstanding that staff working nights have not received medications training and therefore there are not staff on duty for all shifts who are trained in the administration of medicines. A sample of staff personnel records were examined. These did not include all required information. There was not a proof of identity in one file and only one reference available in one file. Criminal Records Bureau checks were continuing to be stored as a complete document which is against the Criminal Records Bureau Code of Practice for the Handling of Disclosure Information. There were no volunteers being currently used at the home. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,36 There was little evidence of quality assurance and ongoing monitoring systems being implemented in order to ensure that service users receive a responsive and quality service. EVIDENCE: There was no documentary evidence that monthly quality monitoring by the Provider was being undertaken. This has been highlighted at previous inspections and must be addressed. There was little evidence of quality assurance processes being in place. Some sample questionnaires were available but no completed examples were available. New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 17 Small amounts of money were held safely on service users behalf. Samples of these financial records were examined. One balance recorded did not correlate with the money available. The discrepancy was found to be hairdressing money that had not been taken from the balance sheet. Double signatures for transactions were included and receipts held for purchases made. Not all records were available as listed by the Schedules in the Care Homes Regulations 2001. Staff supervision records were examined these indicated that whilst some supervision of staff was taking place the frequency of this was irregular. This is an outstanding requirement from previous inspections New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 3 x 3 x x 3 x 2 STAFFING Standard No Score 27 x 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 2 2 2 x New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) 17(1a) Sch 3 Requirement If the MAR chart is handwritten or altered by a member of staff this must be signed and dated by them. This must then be checked, signed and dated by a second member of staff Timescale for action 31/12/05 2 OP9 Previous timescale April 2005 13(2)17 Staff with training in the storage (1)(a) Sch and administration of medicines 3 must on duty for all shifts Previous timescale 30.10.05 A record must be kept of the dose of medication administered to a service user where a variable dose is possible. If the instructions to administer a medication are changed by a doctor the entry on the MAR chart must be clearly discontinued and a new entry written with all the relevant information. Residents must be consulted regarding their post death wishes This must be reviewed regularly. Where this is DS0000035586.V270365.R01.S.doc 30/01/06 3 OP9 13(2) 17(1a) S 3 13(2)17 (1a) S3 31/12/05 4 OP9 31/12/05 5 OP11 12 30/03/06 New Bassett House Version 5.0 Page 20 6 OP18 13 & 18 considered inappropriate the reasons for this must be recorded Staff must receive training on the protection of vulnerable adults list and the referral procedures for this Previous timescale July 2005 All staff must training on the protection of vulnerable adults and the locally agreed procedures 28/02/06 7 OP18 13 & 18 28/02/06 8 OP24 12 Previous timescale July 2005 There must be documentary 30/01/06 evidence of Residents being routinely assessed as their ability to hold the key to their rooms and this be offered to them if considered appropriate Previous timescales April 2005, 30.08.05 The cross infection risk of using cans of foam soap for multiple service users must be addressed Chemical cleansers must be securely stored in all areas Criminal Records Bureau disclosures must be handled in accordance with ‘Criminal Records Bureau Code of Conduct for the handling of Disclosure Information’ Previous timescales March 2005 The registered person must ensure that all staff records retained at the home contain the elements described in the Schedules Previous timescale 31.8.04 A quality assurance system must be implemented which audits and responds to the findings of service user, relative and visiting professional opinion of the home DS0000035586.V270365.R01.S.doc 9 10 11 OP26 OP26 OP29 13 13 19 31/12/05 31/12/05 31/12/05 12 OP29 17,18,19 Sch 2 & 4 30/01/05 13 OP33 24 30/03/06 New Bassett House Version 5.0 Page 21 14 OP33 24 15 OP33 26 There must be an annual development plan for the home with timescales which are implemented The home’s line manager must complete a written report of any visits to the home These must be forwarded to the Commission for Social Care Inspection Previous timescale 30.6.04 Records of monies held on suervice users behalf must be accurately kept A plan must be in place to ensure all staff should receive formal supervision at least six times a year Records required by schedules 2,3,and 4 must be available Previous timescale 30.09.05 30/03/06 30/01/06 16 17 OP35 OP36 16 Sch 4 18 31/12/05 28/02/06 18 OP37 17 Sch 2,3,4 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP9 OP29 Good Practice Recommendations Staff from the home should complete a written assessment of the service users prior to admission in order to ensure the service users needs can be met at the home A drug reference book not dated more than one year old should be available A copy of the Criminal Records Bureau Code of Conduct for the handling of Disclosure Information should be obtained New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI New Bassett House DS0000035586.V270365.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!